Failure to Implement Fall-Prevention Interventions and Follow Medication Parameters for High-Risk Resident
Penalty
Summary
Facility staff failed to ensure that safety interventions were consistently in place for a resident with a known high risk for falls and fall-related injury. The resident had multiple significant diagnoses, including a left pubis fracture, diabetes with neuropathy and hyperglycemia, altered mental status, severe protein-calorie malnutrition, anemia, and orthostatic hypotension, and had a recent history of falls with head injury, concussion, transient loss of consciousness, and memory impairment. Medical notes documented that the resident was disoriented, had impaired mobility, chronic pain, and was considered a high fall risk, with instructions to maintain fall precautions and optimize the environment, including keeping the urinal and call bell within reach. Despite these documented risks and care plan interventions, observations on the survey date showed the resident lying in bed with the call bell under the bed and not within reach, and the urinal hanging from a nightstand drawer handle approximately four feet away from the bed, also not within reach. There were no fall mats next to the bed, and later observation with the DON showed the bed in a medium-high position rather than in the lowest position as care planned. The resident reported difficulty standing and a history of multiple serious falls with fractures and skull injuries. The LPN present in the room acknowledged that the call bell was under the bed and expressed uncertainty about who was responsible for placing it on the bed. The resident’s care plan identified the resident as being at risk for falls and fall-related injury related to weakness, diabetes, orthostatic hypotension, pain, anemia, and use of cardiovascular and psychotropic medications, with specific interventions such as ensuring the urinal and common items were within reach, keeping the bed in the lowest position, and reminding the resident to use the call light for assistance. Additionally, the physician’s order for Midodrine specified that the medication should be held if the systolic blood pressure was greater than 120, yet the MAR showed the medication was administered when the systolic blood pressure was 128, outside the ordered parameters. The medical director confirmed that the Midodrine should have been held. Therapy staff described the resident as a fall risk, impulsive, and more sedated than previously, and indicated that if the resident could not reach needed items, the resident would attempt to get out of bed despite knowing it was unsafe.
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